Underlying Systemic Diseases in Pyoderma Gangrenosum: A Systematic Review and Meta-Analysis

BACKGROUND

There is little consensus regarding the prevalence and distribution of underlying systemic diseases among patients with pyoderma gangrenosum.

OBJECTIVE

The objective of this study was to synthesize existing data on the prevalence of associated systemic diseases in patients with pyoderma gangrenosum.

METHODS

We performed a systematic review and meta-analysis of observational studies in MEDLINE, EMBASE, and Scopus (1823-2017). The quality of evidence was assessed using a modified Newcastle-Ottawa Scale. A meta-analysis was performed using random-effects models to estimate pooled prevalence rates with 95% confidence intervals.

RESULTS

Twenty-one eligible studies comprising 2611 patients with pyoderma gangrenosum were included in the quantitative synthesis. The overall random-effects pooled prevalence of associated systemic diseases was 56.8% (95% confidence interval 45.5-67.4). The leading underlying disease was inflammatory bowel disease (17.6%; 95% confidence interval 13.0-22.7), followed by arthritis (12.8%; 95% confidence interval 9.2-16.9), hematological malignancies (8.9%; 95% confidence interval 6.5-11.6), and solid malignancies (7.4%; 95% confidence interval 5.8-9.1). In 16.3% (95% confidence interval 7.7-27.1) of cases, the onset of pyoderma gangrenosum was attributed to the pathergy phenomenon.

CONCLUSIONS

More than half of patients with pyoderma gangrenosum present with a relevant underlying disease. Inflammatory bowel disease and arthritis are the most frequently associated diseases. Relative to the reported literature, the pooled prevalence of arthritis and hematological malignancies is lower, while the pooled prevalence of solid malignancies is higher. Owing to the high level of heterogeneity among most of the comparisons, results should be interpreted with caution.

Pyoderma gangrenosum: An important dermatologic condition occasionally associated with rheumatic diseases

Pyoderma gangrenosum (PG) presents with refractory, sterile, deep ulcers most often on the lower legs. Clinically, PG exhibits four types, i.e., ulcerative, bullous, pustular, and vegetative types. PG may be triggered by surgical operation or even by minor iatrogenic procedures such as needle prick or catheter insertion, which is well-known as pathergy. PG is sometimes seen in association with several systemic diseases including rheumatoid arthritis (RA), inflammatory bowel disease, hematologic malignancy, and Takayasu’s arteritis. In particular, various cutaneous manifestations are induced in association with RA by virtue of the activation of inflammatory cells (neutrophils, lymphocytes, macrophages), vasculopathy, vasculitis, drugs, and so on. Clinical appearances of ulcerative PG mimic rheumatoid vasculitis or leg ulcers due to impaired circulation in patients with RA. In addition, patients with PG sometimes develop joint manifestations as well. Therefore, it is necessary for not only dermatologists but also rheumatologists to understand PG.

Pyoderma gangrenosum--a review of 24 cases observed over 10 years

BACKGROUND AND OBJECTIVES

  Pyoderma gangrenosum (PG) is a disorder, included in the spectrum of neutrophilic and auto-inflammatory dermatoses, whose clinical aspects and outcome we intend to characterize.

MATERIALS AND METHODS

  In a retrospective study based on files of patients diagnosed during a 10-year period (2000-2009), we evaluated demographic data, anatomic locations, number of lesions, clinical variants, associated diseases, treatment regimens, healing time, and recurrence.

RESULTS

  A total of 24 patients were included, 19 women and five men (F/M = 3.8/1), aged between 17 and 89 years (mean 58.3 ± 24.6 years) with a diagnosis of PG. Lesions, single in 15 patients (62.5%) and multiple in nine (37.5%), were localized in the lower limbs in 19 patients (79.2%), upper limbs (4), abdomen (4), face (2) and genital area (1). Clinical variants observed were ulcerative (17 patients), pustular (4), bullous (2) and superficial granulomatous (1). Associated systemic diseases were observed in 18 patients (75%), gastrointestinal in seven patients (29.2%), hematological in seven (25%), autoimmune inflammatory in three (12%), and solid tumors in two (8.3%). Systemic steroids were used in the treatment, either alone in 10 patients (41.7%) or combined with cyclosporine in eight (33.3%). Complete healing was achieved in 20 patients, on average five months after diagnosis, but lesions recurred one or more times in four patients (16.7%).

CONCLUSIONS

  As reported in the literature, PG is a rare disorder, more common in females, frequently associated with systemic disease, which compromises the prognosis.

Pyoderma gangrenosum: an update

Pyoderma gangrenosum (PG) can be differentiated into classic and atypical forms. The classic form is characterized by ulcers and the atypical form by deep erosions with bullous blue-gray margins. Pathergy, the development of cutaneous lesions at sites of trauma, is a common feature of both forms of PG. Approximately 50% of patients who have PG have underlying systemic diseases, most commonly inflammatory bowel disease, myeloproliferative disorders, and various forms of inflammatory arthritis. The diagnosis of PG is one of exclusion. The management of this disorder begins with treatment of any underlying disease and local or systemic glucocorticoids or immunomodulating therapies.